CAPITAL INVESTMENT PLAN APPLICATION

·  A electronic copy of this template is available at: http://www.mae.gov.nl.ca/for/gta.html

Contact Information:

Name of Municipality/Inuit Community Government:

______

Contact Name:

Phone:

Is this a Revised Project: Yes

No

If yes, please indicate Project Number: ______

Identification of Proposed Project:

Project Title:

Eligible Project Category:

Tick one of the appropriate categories

Local Roads and Bridges Drinking Water

Highways Wastewater

Short-sea Shipping Solid Waste

Short-line rail Community Energy Systems

Brownfield Redevelopment Sport Infrastructure

Broadband Connectivity Recreational Infrastructure

Public Transit Disaster Mitigation

Cultural Infrastructure Capacity Building

Tourism Infrastructure

1) Description of the proposed project, including the project location.

(If other municipalities are involved in this project, please indicate the names of the municipalities. Provide the specific location (street name) of the project and a site map or plan, if available)

2) Proposed Project Financing

(A)
Gas Tax Funding / (B)
Municipal Funding / (C)
Provincial
Funding / (D)
Other Federal
Funding / (E)
Other Funding / (A) +(B)+(C)+(D)+(E)
Total Estimated
Project Cost

Ø  Does this project require signage, as per the Infrastructure Project sign Design and Installation Guidelines (http://www.mae.gov.nl.ca/for/gta.html.)

Yes

No

If yes, please ensure the cost is included in the Total Estimated Project Cost and a quote is attached.

Ø  Will this project receive (or has the project received) funding from other provincial/federal programs? Y N

Ø  If yes, please indicate the name of the provincial/federal program(s), as well as the associated project number:

Ø  What is the estimated starting date of the proposed project?

Ø  What is the estimated completion date of the proposed project?

3) How will this project provide a beneficial impact on your community?

______

______

______

4) Does this project relate to infrastructure owned by the municipality/ICG? Y N

If no, who owns the infrastructure? ______

REMINDER: Attach the cost estimate and resolution of council for your proposed project.

Submit completed application to:

Gas Tax Secretariat
Department of Municipal Affairs and Environment
Confederation Building, West Block
P.O. Box 8700
St. John's, NL
A1B 4J6
/
Facsimile: (709) 729-3605
E-mail:

Questions:

Please call 1-877-729-4393 or E-mail:

Last updated April 2017 Page 1